Early Operation for Congenital Subluxation of the Knee
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Abstract:
A technique is described for the early correction of congenital anterior subluxation of the knee by soft tissue release. After 5 years, the results of operation in three knees were encouraging and superior to the reported results of late correction of the established deformity.Keywords:
Subluxation
The contributions made by metatarsus primus varus, medial subluxation of the navicular, and angulation of the neck of the talus to the residual deformity in treated club feet were assessed from radiographs. Their relation to the appearance of the feet, to the age of the patient, to the results of operations, and to the age at the time of the first operation were investigated. Lateral rotation of the ankle and flattening of the talus were also studied. Medial subluxation of the navicular was found to be the most important factor influencing both the appearance of the feet and the lateral rotation of the ankle. Relocation of the talonavicular joint correlated with the success of operative treatment; and the timing of the primary operation determined the degree of relocation which could be achieved. Metatarsus primus varus and angulation of the talus were of little importance. Increased emphasis is given to the need for early relocation of the talonavicular joint.
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Spinal Deformity
Subluxation
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We evaluated the clinical and radiological outcomes in 16 patients (15 women) having rheumatoid arthritis with a mean age of 66 (55-77) years, on average 2 (1-5) years after decompression and stabilization, for subaxial subluxation of the cervical spine. The duration of rheumatoid arthritis averaged 30 (10-67) years and the duration of neck symptoms averaged 15 (1-60) months. Preoperatively, 11 of the patients had pain in the neck, all 16 suffered from arm rhizopathy and varying degrees of myelopathy. 4/5 patients with severe myelopathy died within 3 months of surgery. Fixation failure occurred in 7 patients, but had no clinical significance in 5. There were 1 deep infection and 1 nerve root lesion resulting in deltoid weakness. Other complications were dysphagia and donor-site pain. 4 reoperations were performed, 2 extension of fusion, 1 revision of infection, and 1 foraminotomy. Neck pain was reliably relieved, while arm rhizopathy was less positively affected. Myelopathy carried a poor prognosis for relief and its occurrence correlated with death. Early treatment, before significant myelopathy has developed, is recommended. Decompression, both via realignment and bone resection, followed by fusion of the entire cervical spine, is advocated. Due to the poor bone quality and with the presently available implant systems, simultaneous anterior and posterior fixation is beneficial.
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Neck pain
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Category: Other; Hindfoot; Midfoot/Forefoot Introduction/Purpose: Identifying markers of severity and progression in Progressive Collapsing Foot Deformity (PCFD) provides surgeons with critical information, possibly aiding in the decision making along the treatment algorithm. Subtalar middle facet subluxation (MFS), the percent undercoverage of the talus in relation to its calcaneus counterpart, was recognized as a reliable marker in weight-bearing computerized tomography (WBCT) for PCFD diagnosis. The Foot and Ankle Offset (FAO), the relative position between the center of the ankle joint and the foot tripod, is a three-dimensional WBCT tool predictive of disease severity. Our objective is to assess the relationship between the amount of MFS and FAO in flexible PCFD patients. We hypothesize that MFS is a reliable assessment of disease severity and correlates with FAO. Methods: In this retrospective IRB-approved comparative study, a total of 56 individuals with PCFD (74 feet) who underwent WBCT for baseline assessment were analyzed. Two blinded fellowship-trained foot and ankle surgeons performed the measurements. MFS was executed in the coronal-plane, at the midpoint (on sagittal-plane) of the middle facet (see attached figure). Dedicated software was utilized to perform the FAO, using the most plantar voxels of the first metatarsal, fifth metatarsal, calcaneal tuberosity and centre of the ankle. Interobserver agreement was quantified for MFS and FAO using intraclass correlation coefficient (ICC). Intermethod agreement between MFS and FAO was assessed by Spearman's correlation. Bivariate linear regression analysis was used to assess the relationship between MFS and FAO. A partition prediction model and multivariate analysis were utilized to assess influence of MFS measurements on FAO values and vice versa. Results: A total of 56 patients (74 feet) were included in the study. The ICCs for interobserver reliability was 0.87 for MFS and 0.95 for FAO. In a bivariate analysis, MFS and FAO were found to be significantly and linearly correlated (P< 0.0001, R2 0.26). Foot Angle Offset = 2.22 + 0.12*Medial Facet Subluxation (%). In multivariate analysis, FAO and body mass index (BMI) were significantly correlated with MFS (<0.001 and 0.02, respectively). The partition prediction model demonstrated that an MFS of 27.5% was an important threshold for increased FAO, with FAO of 3.4% +-2.4% when MFS was below threshold and 8.0% +-3.5% when above threshold. Conclusion: We found a positive linear correlation between MFS and FAO measurements. An MFS of 27.5% was an important threshold for higher FAO values, which corresponded to a worst overall alignment. Our results are consistent with the idea that MFS is a reliable marker for PCFD diagnoses and severity, correlating well with the FAO. This data may support clinical decisions in PCFD patients. Also, BMI was found to be positively correlated with MFS. Future prospective and longitudinal studies are needed to confirm the findings of this study.
Subtalar joint
Foot (prosody)
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Ten subjects with unilateral posterior cruciate ligament- deficient knees were studied, comparing the knee mechanics of the affected knee with the mechanics of the opposite normal knee. The static squat test was used to determine knee forces and moments through measurements made on roentgenograms. Statistically significant increases occurred in posterior translation of the tibia in all knees at high knee flexion angles, but not uniformly at low knee flexion angles. The results suggest that posterior tibial subluxation occurs in vivo during certain activities of daily living. Posterior tibial subluxation occurred in positions of knee flexion near 70°, establishing a new equilibrium for the system where tibiofemoral joint compression force (approximately four times one-half body weight) remained an order of magnitude greater than tibiofemoral shear forces (approximately 10% of one-half body weight).
Posterior cruciate ligament
Subluxation
Knee flexion
Squat
Biomechanics
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Category: Midfoot/Forefoot; Basic Sciences/Biologics; Hindfoot Introduction/Purpose: The current classification system of progressive collapsing foot deformity (PCFD) is comprised of 5 possible classes that describe different deformity components. Each class is defined by clinical and radiographic findings. These components are ostensibly independent from one another during evaluation and treatment. However, PCFD is understood to be a complex, three-dimensional deformity occurring in many regions along the foot and ankle. The question remains whether a deformity in one area impacts other areas. The objective of this study is to assess how each one of the classes is influenced by other classes by evaluating each associated angular measurement. We hypothesized that positive and linear correlations would occur for each class with at least one other class and that this influence would be high. Methods: In this IRB-approved retrospective case-control study, we assessed 32 feet diagnosed with PCFD and 28 controls matched on gender, BMI and age. All measurements were performed using weight-bearing CT (WBCT) scans and completed by two foot and ankle surgeons. The classes and their associated radiographic measurements were defined as follows: Class A (hindfoot valgus) measured by the hindfoot moment arm (HMA), class B (midfoot abduction) measured by the talonavicular coverage angle (TNCA), class C (medial column instability) measured by the talus-first metatarsal (Meary) angle, class D (peritalar subluxation) measured by the medial facet uncoverage (MFU), and class E (ankle valgus) measured using the talar tilt angle (TTA). Multivariate analyses were completed comparing each class measurement to the other classes. Data were checked for multicollinearity with the Belsley-Kuh-Welsch technique. Heteroskedasticity and normality of residuals were assessed respectively by the Breusch-Pagan test and the Shapiro-Wilk test. A p-value <0.05 was considered significant. Results: After removing confounding variables, each class was separately evaluated. In Class A, Meary was positively correlated (rs=0.46; p=0.009) with HMA, explaining 21% of changes in this angle (R2=0.21). Class B evaluation showed that MFU was correlated with TNCA (rs=0.76; p=0.001), explaining 63% of TNCA variations (R2=0.63). In Class C, HMA (rs=0.71; p=0.001) and MFU (rs =0.75; p=0.001) were correlated to Meary's angle and both measures explained 58% of changes in this angle (R2=0.58). When assessing Class D, TNCA (rs =0.76; p=0.001) and Meary (rs=0.75; p=0.001) correlated with MFU and were responsible for 63% of variations on this angle. Finally, Class E deformity, determined by TTA, was not correlated with any other measurement. Conclusion: This study was able to find relations between components of PCFD deformity with exception of ankle valgus (Class E). Measurements associated with each class were found to be influenced by others, and in some instances with pronounced strength. The presented data may support the notion that PCFD is a three-dimensional complex deformity and suggests a possible relation among its ostensibly independent features. Further, these results support the concept that a specific component correction may impact other misalignments, decreasing the necessity for adjuvant procedures. This could have a direct effect in clinical practice, changing how providers assess PCFD and plan treatments.
Valgus deformity
Foot (prosody)
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A method for axial radiography of the patellofemoral joint has been developed that combines a forced lateral rotation of the leg with 30 degrees flexion of the knee. This view can be obtained without any special device and is definitely superior to the 45 degrees routine axial view in the detection of lateral subluxation of the patella. It should be obtained when patellar instability is suspected.
Subluxation
Patellofemoral joint
External rotation
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Triple arthrodesis
Subluxation
Avascular Necrosis
Varus deformity
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Seventy-nine consecutive children with cerebral palsy who underwent osteotomies about the hip for subluxation or dislocation were studied retrospectively to determine risk factors that would correlate with postoperative complications of death, fracture, or decubitus ulcer. Except for the three patients who died, all of the children had > or = 1 year of follow-up. Twenty (25%) patients had at least one complication. Three children died; one at 1 week, one at 2 weeks, and one at 5 months after surgery. Sixteen patients sustained 25 fractures. All were managed with cast or splint immobilization in the clinic. Five patients developed decubitus ulcers requiring > or = 2 weeks of local care, but none required skin grafts or flaps. Complications occurred in 13 (68%) of 19 children with gastrostomies or tracheostomies but in only seven (12%) of the remaining 60 children. Only one (8%) of 13 ambulatory patients had a complication compared with 19 (29%) of 66 nonambulatory patients. In conclusion, ambulatory function correlates well with the risk of complications after osteotomies. A nonambulatory patient with a gastrostomy or tracheostomy is at even greater risk. Fortunately the fractures and ulcers observed in this series healed uneventfully with no operative intervention.
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